Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

RUMI KOH EFFICIENT3.5 KCRUMI35

Facility

$594.00

Hospital Revenue Code	272
Min. Negotiated Rate	$302.94
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Hawaii Western Management Group Commercial	$564.30
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Kaiser Permanente Commercial	$374.22
Rate for Payer: Kaiser Permanente Medicaid	$302.94
Rate for Payer: MDX Hawaii PPO	$576.18
Rate for Payer: University Health Alliance Commercial	$432.97

RUMI KOH EFFICIENT3.5 KCRUMI35

Facility

$594.00

Hospital Revenue Code	272
Min. Negotiated Rate	$504.90
Max. Negotiated Rate	$576.18
Rate for Payer: Cash Price	$356.40
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$576.18

SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL) [430173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	250
Min. Negotiated Rate	$3,040.45
Max. Negotiated Rate	$3,469.69
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: MDX Hawaii PPO	$3,469.69

SACITUZUMAB GOVITECAN-HZIY 180 MG/18ML IV (WET SOLR VIAL) [430173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	636
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$3,469.69
Rate for Payer: AlohaCare Medicaid	$36.80
Rate for Payer: AlohaCare Medicare	$36.80
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Devoted Health Medicare	$40.48
Rate for Payer: Hawaii Medical Service Association ABD	$36.26
Rate for Payer: Hawaii Medical Service Association Commercial	$46.00
Rate for Payer: Hawaii Medical Service Association Medicare	$36.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.26
Rate for Payer: Hawaii Western Management Group Commercial	$3,398.15
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Humana Medicare	$36.80
Rate for Payer: Kaiser Permanente Commercial	$2,253.51
Rate for Payer: Kaiser Permanente Medicaid	$1,824.27
Rate for Payer: Kaiser Permanente Medicare	$36.80
Rate for Payer: MDX Hawaii PPO	$3,469.69
Rate for Payer: Ohana Health Plan Medicaid	$40.48
Rate for Payer: Ohana Health Plan Medicare	$36.80
Rate for Payer: UnitedHealthcare Medicaid	$2,146.20
Rate for Payer: UnitedHealthcare Medicare	$36.80
Rate for Payer: University Health Alliance Commercial	$2,607.28

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	636
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$3,469.69
Rate for Payer: AlohaCare Medicaid	$36.80
Rate for Payer: AlohaCare Medicare	$36.80
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Devoted Health Medicare	$40.48
Rate for Payer: Hawaii Medical Service Association ABD	$36.26
Rate for Payer: Hawaii Medical Service Association Commercial	$46.00
Rate for Payer: Hawaii Medical Service Association Medicare	$36.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.26
Rate for Payer: Hawaii Western Management Group Commercial	$3,398.15
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: Humana Medicare	$36.80
Rate for Payer: Kaiser Permanente Commercial	$2,253.51
Rate for Payer: Kaiser Permanente Medicaid	$1,824.27
Rate for Payer: Kaiser Permanente Medicare	$36.80
Rate for Payer: MDX Hawaii PPO	$3,469.69
Rate for Payer: Ohana Health Plan Medicaid	$40.48
Rate for Payer: Ohana Health Plan Medicare	$36.80
Rate for Payer: UnitedHealthcare Medicaid	$2,146.20
Rate for Payer: UnitedHealthcare Medicare	$36.80
Rate for Payer: University Health Alliance Commercial	$2,607.28

SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION [173279]

Facility

$3,577.00

Service Code	HCPCS J9317
Hospital Revenue Code	250
Min. Negotiated Rate	$3,040.45
Max. Negotiated Rate	$3,469.69
Rate for Payer: Cash Price	$2,146.20
Rate for Payer: Health Management Network Commercial	$3,040.45
Rate for Payer: MDX Hawaii PPO	$3,469.69

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$29.00

Service Code	NDC 62332055660
Hospital Revenue Code	637
Min. Negotiated Rate	$14.79
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$18.27
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: University Health Alliance Commercial	$21.14

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$36.00

Service Code	NDC 00078065920
Hospital Revenue Code	637
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: University Health Alliance Commercial	$26.24

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$36.00

Service Code	NDC 00078065920
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET [129911]

Facility

$29.00

Service Code	NDC 62332055660
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: MDX Hawaii PPO	$28.13

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$36.00

Service Code	NDC 00078077720
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$29.00

Service Code	NDC 62332055760
Hospital Revenue Code	250
Min. Negotiated Rate	$24.65
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: MDX Hawaii PPO	$28.13

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$29.00

Service Code	NDC 62332055760
Hospital Revenue Code	637
Min. Negotiated Rate	$14.79
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$17.40
Rate for Payer: Hawaii Western Management Group Commercial	$27.55
Rate for Payer: Health Management Network Commercial	$24.65
Rate for Payer: Kaiser Permanente Commercial	$18.27
Rate for Payer: Kaiser Permanente Medicaid	$14.79
Rate for Payer: MDX Hawaii PPO	$28.13
Rate for Payer: University Health Alliance Commercial	$21.14

SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET [129912]

Facility

$36.00

Service Code	NDC 00078077720
Hospital Revenue Code	637
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: University Health Alliance Commercial	$26.24

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [129913]

Facility

$36.00

Service Code	NDC 00078069620
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: MDX Hawaii PPO	$34.92

SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET [129913]

Facility

$36.00

Service Code	NDC 00078069620
Hospital Revenue Code	637
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$34.92
Rate for Payer: Cash Price	$21.60
Rate for Payer: Hawaii Western Management Group Commercial	$34.20
Rate for Payer: Health Management Network Commercial	$30.60
Rate for Payer: Kaiser Permanente Commercial	$22.68
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: MDX Hawaii PPO	$34.92
Rate for Payer: University Health Alliance Commercial	$26.24

SAFE SHEATH 6FX13

Facility

$200.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

SAFE SHEATH 6FX13

Facility

$200.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$478.55
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: MDX Hawaii PPO	$546.11

SAFESHEATH 8X23

Facility

$563.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$287.13
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$534.85
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$354.69
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$410.37

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

SAFESHEATH II SS6 398339

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$120.36
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$148.68
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: University Health Alliance Commercial	$172.02

SAFESHEATH II SS8 398343

Facility

$236.00

Service Code	HCPCS C1892
Hospital Revenue Code	272
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: MDX Hawaii PPO	$228.92

SAFETY PEG KIT 20FR

Facility

$586.00

Hospital Revenue Code	272
Min. Negotiated Rate	$298.86
Max. Negotiated Rate	$568.42
Rate for Payer: Cash Price	$351.60
Rate for Payer: Hawaii Western Management Group Commercial	$556.70
Rate for Payer: Health Management Network Commercial	$498.10
Rate for Payer: Kaiser Permanente Commercial	$369.18
Rate for Payer: Kaiser Permanente Medicaid	$298.86
Rate for Payer: MDX Hawaii PPO	$568.42
Rate for Payer: University Health Alliance Commercial	$427.14

Know your out-of-pocket cost for care.

All Charges